What is the initial management and treatment for a patient presenting with hematochezia (passage of fresh blood per anus)?

Initial Management and Treatment for Hematochezia

The initial management of hematochezia requires immediate hemodynamic assessment, resuscitation if needed, and urgent endoscopic evaluation within 24 hours for patients with severe bleeding or high-risk features. 1

Initial Assessment and Resuscitation

• Assess hemodynamic status immediately, including vital signs (heart rate, blood pressure) to determine the severity of bleeding 1
• Establish two large-bore venous cannulae for rapid fluid and blood product administration 1
• Begin crystalloid infusion to restore blood pressure, with a target mean arterial pressure >65 mmHg 2
• For severe bleeding with hemodynamic instability, initiate blood transfusion with a restrictive strategy (hemoglobin threshold of 7 g/dL, target 7-9 g/dL) 2
• Insert urinary catheter to monitor hourly urine output (target >30 mL/hr) in severe cases 1
• Perform laboratory tests including complete blood count, serum electrolytes, blood urea nitrogen, creatinine, and coagulation profile 2
• Blood typing and cross-matching should be ordered for patients with signs of severe bleeding 2

Diagnostic Approach

• Perform nasogastric lavage to exclude upper gastrointestinal source, especially in patients with severe hematochezia and hypovolemia 2
• If blood, clots, or coffee grounds material is present in the nasogastric aspirate, upper endoscopy must be performed 2
• Consider upper endoscopy early, as 10-15% of severe hematochezia cases have an upper gastrointestinal source 2
• After hemodynamic stabilization, urgent colonoscopy within 24 hours is the diagnostic procedure of choice for lower gastrointestinal bleeding 2, 1
• Rapid bowel preparation (purge) before colonoscopy improves visualization and diagnostic yield 3
• If colonoscopy is negative or bleeding is ongoing, consider CT angiography to localize the bleeding site 2, 1

Therapeutic Interventions

• Endoscopic therapy should be performed if a bleeding source is identified during colonoscopy 2
• For patients with anorectal varices and severe bleeding, maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg while avoiding fluid overload 2
• Consider temporary discontinuation of antiplatelet agents or anticoagulants during the acute bleeding episode 2, 1
• For bleeding that cannot be controlled endoscopically, consider angiographic embolization or surgery 2
• Surgical intervention is indicated for life-threatening bleeding with persistent hemodynamic instability despite resuscitation 2

Special Considerations

• In patients with inflammatory bowel disease and massive bleeding, a multidisciplinary approach involving gastroenterology and surgery is recommended 2
• For suspected anorectal varices, involve hepatology specialists early and optimize management of portal hypertension 2
• In young patients (<50 years), although anal causes (hemorrhoids) are common, colorectal cancer should still be considered 4
• For patients with radiation proctitis causing bleeding, formalin application may be considered as a treatment option 2

Common Pitfalls to Avoid

• Do not delay resuscitation to perform diagnostic procedures; stabilization takes priority 1
• Avoid over-transfusion as it may increase portal pressure in patients with varices 2, 1
• Do not proceed to emergency surgery without attempting to localize bleeding through endoscopic or radiological methods first 1
• Do not assume all hematochezia in young patients is from hemorrhoids; complete evaluation is often necessary 5, 4
• Do not rely solely on clinical assessment to distinguish between significant and non-significant causes of bleeding 5